Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
What is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia?
A. Risk for injury related to depressed sensorium.
Risk for injury related to depressed sensorium. This choice is not the most appropriate nursing diagnosis for a child with moderate anemia. While anemia can lead to fatigue and weakness, the main concern is the child's ability to tolerate physical activities, not the risk of injury due to a depressed sensorium.
B. Decreased cardiac output related to abnormal hemoglobin.
Decreased cardiac output related to abnormal hemoglobin. This choice is not the most suitable nursing diagnosis for a child with moderate anemia. While abnormal hemoglobin levels can affect cardiac output, moderate anemia typically doesn't lead to such a significant decrease in cardiac output that it becomes the primary nursing diagnosis. Activity intolerance is a more relevant concern.
C. Activity intolerance related to generalized weakness.
Activity intolerance related to generalized weakness. This is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia. Moderate anemia results in a decrease in oxygen-carrying capacity, leading to generalized weakness and reduced ability to perform physical activities without becoming fatigued. The child's hemoglobin levels are likely low enough to cause noticeable activity intolerance.
D. Risk for Injury related to dehydration and abnormal hemoglobin.
Risk for Injury related to dehydration and abnormal hemoglobin. This choice is not the best nursing diagnosis for a child with moderate anemia. Dehydration may exacerbate the effects of anemia, but the primary issue here is the anemia itself causing weakness and activity intolerance, which are better addressed with the choice C diagnosis.
This question is an excerpt from Nurse Dive's nursing test bank - Pediatrics Midterm V1 2023 Test 3 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is choice C. Activity intolerance related to generalized weakness.
Choice A rationale:
Risk for injury related to depressed sensorium. This choice is not the most appropriate nursing diagnosis for a child with moderate anemia. While anemia can lead to fatigue and weakness, the main concern is the child's ability to tolerate physical activities, not the risk of injury due to a depressed sensorium.
Choice B rationale:
Decreased cardiac output related to abnormal hemoglobin. This choice is not the most suitable nursing diagnosis for a child with moderate anemia. While abnormal hemoglobin levels can affect cardiac output, moderate anemia typically doesn't lead to such a significant decrease in cardiac output that it becomes the primary nursing diagnosis. Activity intolerance is a more relevant concern.
Choice C rationale:
Activity intolerance related to generalized weakness. This is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia. Moderate anemia results in a decrease in oxygen-carrying capacity, leading to generalized weakness and reduced ability to perform physical activities without becoming fatigued. The child's hemoglobin levels are likely low enough to cause noticeable activity intolerance.
Choice D rationale:
Risk for Injury related to dehydration and abnormal hemoglobin. This choice is not the best nursing diagnosis for a child with moderate anemia. Dehydration may exacerbate the effects of anemia, but the primary issue here is the anemia itself causing weakness and activity intolerance, which are better addressed with the choice C diagnosis.
Similar Questions
A nurse is charting that a hospitalized child has labored breathing. Which medical term describes labored breathing?
A. Orthopnea.
Orthopnea. Orthopnea refers to difficulty in breathing that occurs when lying flat. It is not the term used to describe labored breathing, which is the main concern in this question.
B. Hypopnea.
Hypopnea. Hypopnea is a term used to describe shallow or slow breathing, usually during sleep. It is not the term used to describe the labored breathing mentioned in the question.
C. Dyspnea.
Dyspnea. This is the correct term to describe labored breathing, which is characterized by a subjective sensation of discomfort or difficulty in breathing. In this context, the nurse is charting that the hospitalized child has labored breathing, indicating the need for further assessment and intervention to address this breathing difficulty.
D. Tachypnea.
Tachypnea. Tachypnea refers to abnormally fast breathing. While it is a concern, especially in the context of a hospitalized child, it does not specifically describe labored breathing, which is the main focus of this question.
Full Explanation
The correct answer is choice C. Dyspnea.
Choice A rationale:
Orthopnea. Orthopnea refers to difficulty in breathing that occurs when lying flat. It is not the term used to describe labored breathing, which is the main concern in this question.
Choice B rationale:
Hypopnea. Hypopnea is a term used to describe shallow or slow breathing, usually during sleep. It is not the term used to describe the labored breathing mentioned in the question.
Choice C rationale:
Dyspnea. This is the correct term to describe labored breathing, which is characterized by a subjective sensation of discomfort or difficulty in breathing. In this context, the nurse is charting that the hospitalized child has labored breathing, indicating the need for further assessment and intervention to address this breathing difficulty.
Choice D rationale:
Tachypnea. Tachypnea refers to abnormally fast breathing. While it is a concern, especially in the context of a hospitalized child, it does not specifically describe labored breathing, which is the main focus of this question.
What are the earliest recognizable clinical manifestations of cystic fibrosis (CF)?
A. Meconium ileus.
Meconium ileus. This is the earliest recognizable clinical manifestation of cystic fibrosis (CF). Meconium ileus refers to the blockage of the small intestine by thick, sticky meconium, the earliest stool of a newborn. It occurs in the first 24-48 hours of life and can be a sign of underlying cystic fibrosis.
B. Foul-smelling, frothy, greasy stools.
Foul-smelling, frothy, greasy stools. Foul-smelling, frothy, greasy stools are characteristic of malabsorption, which can occur in cystic fibrosis. However, this manifestation typically appears after meconium ileus and is not the earliest recognizable clinical sign.
C. History of poor intestinal absorption.
History of poor intestinal absorption. While poor intestinal absorption is a common consequence of cystic fibrosis, it is not one of the earliest recognizable clinical manifestations. Meconium ileus takes precedence as the primary early sign.
D. Recurrent pneumonia and lung infections.
Recurrent pneumonia and lung infections. Recurrent pneumonia and lung infections are common in later stages of cystic fibrosis due to the buildup of thick mucus in the respiratory tract. However, they are not among the earliest recognizable clinical manifestations of the disease. Meconium ileus is the earliest indicator in this context.
Full Explanation
The correct answer is choice A. Meconium ileus.
Choice A rationale:
Meconium ileus. This is the earliest recognizable clinical manifestation of cystic fibrosis (CF). Meconium ileus refers to the blockage of the small intestine by thick, sticky meconium, the earliest stool of a newborn. It occurs in the first 24-48 hours of life and can be a sign of underlying cystic fibrosis.
Choice B rationale:
Foul-smelling, frothy, greasy stools. Foul-smelling, frothy, greasy stools are characteristic of malabsorption, which can occur in cystic fibrosis. However, this manifestation typically appears after meconium ileus and is not the earliest recognizable clinical sign.
Choice C rationale:
History of poor intestinal absorption. While poor intestinal absorption is a common consequence of cystic fibrosis, it is not one of the earliest recognizable clinical manifestations. Meconium ileus takes precedence as the primary early sign.
Choice D rationale:
Recurrent pneumonia and lung infections. Recurrent pneumonia and lung infections are common in later stages of cystic fibrosis due to the buildup of thick mucus in the respiratory tract. However, they are not among the earliest recognizable clinical manifestations of the disease. Meconium ileus is the earliest indicator in this context.
It is now recommended that children with asthma who are taking long-term inhaled steroids should be assessed frequently to monitor for what increased risk?
A. Slowed growth.
Slowed growth is a potential risk associated with long-term use of inhaled steroids in children with asthma. Inhaled steroids are a cornerstone of asthma management due to their anti-inflammatory effects on the airways, but they can have systemic effects when absorbed in larger amounts. Prolonged use of these steroids can potentially lead to growth suppression in children by affecting the normal growth and development of bones and other tissues.
B. Osteoporosis.
Osteoporosis is not the primary concern in children taking inhaled steroids. While long-term use of high-dose systemic steroids can lead to bone loss and osteoporosis in adults, the risk of osteoporosis is much lower in children receiving inhaled steroids for asthma management. Inhaled steroids have a lower systemic absorption, reducing the risk of significant bone density reduction in children.
C. Cushing's syndrome.
Cushing's syndrome is a condition caused by prolonged exposure to high levels of cortisol, often due to excessive use of systemic steroids. Inhaled steroids, especially at recommended doses, have a lower likelihood of causing Cushing's syndrome compared to systemic steroids. The systemic absorption of inhaled steroids is limited, minimizing the risk of this syndrome.
D. Cough.
Cough is not the primary increased risk associated with long-term use of inhaled steroids in children with asthma. Inhaled steroids are actually used to help control and prevent asthma symptoms, including cough. They work by reducing inflammation in the airways, which helps alleviate symptoms like coughing, wheezing, and shortness of breath.
Full Explanation
The correct answer is choice A. Slowed growth.
Choice A rationale:
Slowed growth is a potential risk associated with long-term use of inhaled steroids in children with asthma. Inhaled steroids are a cornerstone of asthma management due to their anti-inflammatory effects on the airways, but they can have systemic effects when absorbed in larger amounts. Prolonged use of these steroids can potentially lead to growth suppression in children by affecting the normal growth and development of bones and other tissues.
Choice B rationale:
Osteoporosis is not the primary concern in children taking inhaled steroids. While long-term use of high-dose systemic steroids can lead to bone loss and osteoporosis in adults, the risk of osteoporosis is much lower in children receiving inhaled steroids for asthma management. Inhaled steroids have a lower systemic absorption, reducing the risk of significant bone density reduction in children.
Choice C rationale:
Cushing's syndrome is a condition caused by prolonged exposure to high levels of cortisol, often due to excessive use of systemic steroids. Inhaled steroids, especially at recommended doses, have a lower likelihood of causing Cushing's syndrome compared to systemic steroids. The systemic absorption of inhaled steroids is limited, minimizing the risk of this syndrome.
Choice D rationale:
Cough is not the primary increased risk associated with long-term use of inhaled steroids in children with asthma. Inhaled steroids are actually used to help control and prevent asthma symptoms, including cough. They work by reducing inflammation in the airways, which helps alleviate symptoms like coughing, wheezing, and shortness of breath.